Why Are So Many Foster Care Children Taking Antipsychotics?

More than 8% of children in foster care have received antipsychotic medication, and just over one quarter of those in foster care who also receive disability benefits take these drugs, according to a recent study in the journal Pediatrics.

The question is why? Children in foster care have typically been neglected or abused — indeed, simply removing a young child from his or her parents, even abusive ones, is in itself traumatic — so, not surprisingly, kids in foster care are more likely to suffer from psychiatric and behavioral problems than those who have stable families. Previous data suggest that foster-care children are about twice as likely as those outside the system to receive psychiatric medications.

Whether these problems are leading to higher rates of antipsychotic use, however, is not clear. “I think we have clinicians facing some very challenging situations,” says Susan dosReis, associate professor at the University of Maryland School of Pharmacy and lead author of the study. “But we don’t have information as to why the prescribers decided on these medications for [these particular] youths.”

The numbers suggest that the influence of pharmaceutical company marketing cannot be overlooked. Ninety-nine percent of youth receiving antipsychotic medications in the study were given atypical antipsychotics — the newer generation of these drugs, which are expensive and mostly unavailable in generic form and have been heavily advertised.

All of the major manufacturers of these drugs have been fined by the Food and Drug Administration for illegal marketing practices — in part, for marketing the drugs for unapproved use in children — with some convicted of criminal charges.

Eli Lilly, which manufactures the atypical antipsychotic Zyprexa, paid out $1.42 billion in 2009 — $615 million of that to settle criminal charges. The charges against Lilly involved selling Zyprexa to doctors for use in children, despite the fact that it was not approved for this age group.

Bristol Myers Squibb paid $515 million in 2007 to settle charges that it also illegally pushed its antipsychotic Abilify to child psychiatrists. Pfizer paid out $301 million in a similar case related to its drug Geodon. AstraZeneca paid out $520 million to settle charges over the drug Seroquel. In all of these cases, the drugs were sold for unapproved use in youth.

The new study by dosReis and colleagues included records of more than 600,000 children enrolled in Medicaid in 2003, including those in foster care, those receiving disability benefits for mental diagnoses, and those on the welfare program called Temporary Assistance for Needy Families. Overall, nearly 3% of all youth on Medicaid received at least one prescription for an antipsychotic medication that year, which is itself a high proportion, especially given that the main condition that antipsychotics are approved to treat —schizophrenia — is extremely rare in children. The rate of schizophrenia in children under 12 is an estimated 2 cases per 1 million children; it affects fewer than 1% of older teens. Antipsychotics are also approved to treat bipolar disorder, a diagnosis that is highly controversial in children. Some studies suggest that it affects 0.2% to 0.4 % of children, and up to 1% of adolescents.

And yet, between 1994 and 2003, rates of bipolar diagnoses in youth under 19 rose by a factor of more than 40, according to the National Institute on Mental Health. It seems unlikely to be a coincidence that this rise occurred during the period when atypical antipsychotics were being illegally marketed for children.

Indeed, most of the antipsychotics used in foster-care youth were for conditions that the drugs were not approved to treat. Fifty-three percent of prescriptions were written for attention deficit/hyperactivity disorder (ADHD), a condition that is ordinarily managed with drugs that have the opposite pharmacological effects as antipsychotics. The stimulant medications like Adderall and Ritalin, widely used for ADHD, tend to increase levels of dopamine, while antipsychotics tend to decrease it.

Moreover, 38% of youth in foster care and 34% of foster-care youth receiving disability benefits received simultaneous prescriptions for more than one atypical antipsychotic, for more than three months — a practice that the researchers said “has demonstrated greater adverse effects with only marginal benefits.” Worryingly, black youth were 27% more likely to receive two or more antipsychotics than whites.

“Essentially, medications like antipsychotics can help with mood instability and aggressivity,” says dosReis, explaining that the drugs are often used to treat symptoms rather than conditions. Very little research is available on medication use in children to guide these practices.

“One of the things I would like to see come out of this research is starting to think about monitoring and evaluating the quality of care [these children are receiving]. We’re not supporting or condoning these practices. One extreme says that no one should get these medications, and that’s as irrational as saying we should be using more,” she says.

The risks of long-term prescribing of atypical antipsychotics to children, whose brains are still developing, are not known. What is known, however, is that the drugs cause severe weight gain in children, and that taking more than one antipsychotic drug may double, even quintuple, the risk of diabetes in youth. In adults, the weight gain associated with use of just one antipsychotic medication increase the risk of diabetes two- to four-fold, which has serious deleterious consequences for long-term health.

Although children in foster care may be genetically and environmentally at higher risk for mental illness, the disproportionately widespread use of antipsychotics in this group is troubling. “This study confirms the need for developmentally and trauma-informed practices in the vulnerable foster-care population,” says Dr. Bruce Perry, founder of the ChildTrauma Academy. “Misunderstanding the pervasive effects of abuse and neglect leads to the mislabeling of behavioral and emotional symptoms in these children and then to overmedication.” (Full disclosure: Dr. Perry is my co-author on two books.)

“The frustrating reality is that there are many evidence-based non-pharmacological interventions that have proven effectiveness and have no adverse effects,” Perry says. Sadly, however, no one is spending billions to push them.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.